HHAL MEDICAL NEWS FEBRUARY 2010

Vitamin D and Colorectal Cancer

Compared with individuals who had the lowest blood levels of 25-hydroxyvitamin D, those who had the highest levels had lower risk for colorectal cancer.

Several small studies have suggested that higher blood levels of vitamin D are associated with lower risk for colorectal cancer (CRC). To examine this association further, investigators conducted a nested, case-control study involving 520,000 participants from the general population in 10 European countries.

Dietary information and blood samples were collected at study enrollment, and circulating 25-hydroxy vitamin D (25[OH]D) levels were measured. The researchers identified 1248 individuals who received diagnoses of incident CRC approximately 4 years, on average, after enrollment. These individuals were matched to 1248 healthy controls. CRC risk estimates were adjusted for potential confounding factors, including body-mass index, smoking status, physical activity, socioeconomic status, and total energy intake, as well as consumption of fruits and vegetables, red and processed meats, and alcohol.

Compared with midlevel 25(OH)D serum concentrations (50–75 nmol/L), lower 25(OH)D concentrations (<25 and 25–50 nmol/L) were associated with higher CRC risks (incidence ratios, 1.32 and 1.28, respectively), and higher concentrations (75–100 and > 100 nmol/L) were associated with lower CRC risks (IRs, 0.88 and 0.77, respectively). Risk reductions in the higher quintiles did not reach significance compared with the middle quintile, but patients in the highest quintile had a 40% lower risk for CRC than those in the lowest quintile (P<0.001). Risk reductions were found for colon cancer but not for rectal cancer, and diminished risk for CRC was associated with greater dietary intake of calcium but not of vitamin D.

Published in Journal Watch Gastroenterology February 26, 2010

Jenab M et al. BMJ 2010 Jan 21; 340:b5500

Test for vitamin D deficiency all year round

Is there a seasonal bias as to when testing is done for vitamin D deficiency? Many physicians test toward the end of the year, although the lowest vitamin D levels occur in the first part of the year. Many elderly patients, however, have vitamin D deficiency throughout the year, arguing for testing to be done whenever patients present with fatigue, myalgias and arthralgias.

Conclusion

Clinicians may have a seasonal bias, favoring testing for vitamin D status in the latter part of the year even though the lowest vitamin D levels are observed in the first part of the year. Although an argument could be made to check for peak 25(OH) vitamin D levels in September and trough levels in March, the seasonal contribution to vitamin D deficiency is overshadowed by ongoing vitamin D deficiency throughout the year. Thus, it may be prudent to test for vitamin D deficiency in patients presenting with fatigue, myalgias, and arthralgias regardless of the season of presentation.

http://www.jamda.com/article/S1525-8610(09)00407-1/abstract

Ca and D

Higher serum 25(OH)D levels were associated with lower levels of nonmelanoma skin cancer in elderly men.

Solar radiation that initiates nonmelanoma skin cancer (NMSC) also initiates vitamin D synthesis in the skin. One might expect that populations with histories of NMSC might also have high serum levels of vitamin D and its more reliably measured precursor, 25(OH)D.

In a recent study, researchers studied the relation between 25(OH)D levels and NMSC risk. Serum levels of 25(OH)D were measured in 1441 randomly selected men enrolled in an osteoporosis study. At baseline and after 5 years, participants were asked whether they had ever had NMSC. Respondents were divided into three groups: never had NMSC (n=930), had NMSC before baseline (n=178), and developed NMSC between baseline and 5 years (n=100). Those in the higher quintiles of 25(OH)D level had less NMSC, even after adjustments for age, body-mass index, season of blood draw, clinic site, smoking, and outdoor walking activity. The odds of having NMSC were 47% lower in the highest quintile than in the lowest quintile. The incident rate (development of NMSC between baseline and 5 years) was also lower in men with adequate 25(OH)D ( 32ng/mL) than in those with lower levels.

Tang JY et al. Cancer Causes Control 2009 Nov 18

Use of Metformin in Obese Adolescents

Weight loss at 1 year was not clinically significant.

Wilson DM et al. Arch Pediatr Adolesc Med 2010 Feb 164:116

Metformin and Vitamin B12 Deficiency

Evidence suggests that metformin lowers vitamin B12 levels in patients with diabetes.

Observational studies have suggested that metformin causes vitamin B₁₂ deficiency in some patients; researchers have proposed several possible mechanisms whereby metformin might interfere with B₁₂ absorption. Understanding this interaction is important, because B₁₂ deficiency could exacerbate neuropathic symptoms in patients with diabetes.

In this prospective case-control study, Canadian investigators identified 122 type 2 diabetic patients with peripheral neuropathy: Half had taken metformin for at least 6 months, and half had never received metformin. Otherwise, clinical characteristics of the groups were similar.

Median serum B₁₂ level was significantly lower in the metformin group than in the no-metformin group (231 vs. 486 pmol/L). Metformin recipients also had significantly higher levels of homocysteine and methylmalonic acid (markers of B₁₂deficiency) and significantly worse scores on standardized clinical assessments of severity of neuropathy. In multivariate analyses controlled for age, duration of diabetes, and glycosylated hemoglobin (HbA_1c) level, metformin therapy was associated independently with worse neuropathic symptoms.

CONCLUSIONS: Metformin exposure may be an iatrogenic cause for exacerbation of peripheral neuropathy in patients with type 2 diabetes. Interval screening for Cbl deficiency and systemic Cbl therapy should be considered upon initiation of, as well as during, metformin therapy to detect potential secondary causes of worsening peripheral neuropathy.

Diabetes Care. 2010 Jan;33(1):156-61

http://www.ncbi.nlm.nih.gov/pubmed/19846797?dopt=Abstract

Metformin's Fishy Smell May Account for Drug Discontinuation

Patients taking generic versions of the diabetes drug metformin may report a "fishy" smell, researchers describe in the Annals of Internal Medicine.

The authors describe two case reports in which patients stopped taking generic metformin after being nauseated by the drug's fish-like smell. Pharmacists have also noted the peculiar odor, "like old locker-room sweat socks," the authors write.

They conclude: "When patients stop taking metformin, physicians should consider inquiring more closely about revulsion to the odor of the medication. Trial of a film-coated, extended-release formulation may be a reasonable approach in such cases."

Annals of Internal Medicine article

Does Offering a Choice of Vegetables Affect Children's Consumption?

Offering a choice of vegetables at meals does not increase consumption.

Zeinstra GG et al. Am J Clin Nutr 2010 Feb 91:349

Statin therapy: Absolute risk of diabetes vs. coronary events
Statin therapy is associated with a slightly increased risk of development of diabetes, but the risk is low both in absolute terms and when compared with the reduction in coronary events. Clinical practice in patients with moderate or high cardiovascular risk or existing cardiovascular disease should not change.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61965-6/abstract

Slow nephropathy in antihypertensive treatment
Initial antihypertensive treatment with benazepril plus amlodipine should be considered in preference to benazepril plus hydrochlorothiazide since it slows progression of nephropathy to a greater extent.

Renal Outcomes Better with Benazepril plus Amlodipine vs. Benazepril plus Hydrochlorothiazide?

Hypertensive patients who take the ACE inhibitor benazepril plus the calcium channel blocker amlodipine have better renal outcomes than those taking benazepril plus the diuretic hydrochlorothiazide, according to a prespecified secondary analysis from the industry-funded ACCOMPLISH trial, published online in the Lancet. Editorialists, however, call the findings into question.

Some 11,500 hypertensive patients at high cardiovascular risk were randomized to take benazepril plus either amlodipine or hydrochlorothiazide. At 3 years, progression of chronic kidney disease — defined as a doubling of serum creatinine or end-stage renal disease — had occurred significantly less often with benazepril-amlodipine than with benazepril-hydrochlorothiazide (2% vs. 4%).

Editorialists point out that the reduction in chronic kidney disease seen with benazepril-amlodipine was "completely driven by the doubling of serum creatinine with no difference in end-stage renal disease, which did not occur much." They say that the benefits of the drug combination were "based on the haemodynamic and not the structural effect," suggesting that there was "no difference in renal protective properties."

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62100-0/abstract

Better sleep quality? Positive mental health? Look to chronic vigorous exercise
A study comparing adolescent athletes to a control group found that chronic vigorous exercise is positively related to higher sleep quality, lower anxiety and fewer depressive symptoms.

In conclusion, along with only two other studies .the present data show that engaging in high amounts of exercise is positively related to favorable sleep patterns and psychological functioning in adolescents. These results provide grounds for promoting ready access to sports activities and for motivating adolescents to exercise regularly, especially male adolescents reporting little exercise behavior.

http://www.jahonline.org/article/S1054-139X(09)00255-9/fulltext

Study: 25% of stroke patients likely will die within a year
A U.S. study published in Neurology found 25% of stroke patients likely will die within one year and 8% will have another attack within a year. Researchers said blacks were at higher risk than whites and the risks increased with age and co-morbidities. MSNBC/Reuters

http://www.msnbc.msn.com/id/35410389/ns/health-heart_health/

Antipsychotic use and hip fracture. Cause and effect?
Hip fractures may occur more in older nursing home patients with dementia who use antipsychotic drugs. Because hip fractures increase mortality, caution should be used when prescribing antipsychotic medications, especially concerning long-term use of antipsychotics

Conclusion :APs appear to increase the risk of hip fracture among older adults with dementia residing in an NH. Hip fractures may be a contributory mechanism to the increased risk mortality observed among AP users. Journal of the American Medical Directors Association

http://www.jamda.com/article/PIIS1525861009003673/abstract

Mediterranean diet may protect against brain infarcts
An NIH-funded study found that people who follow a Mediterranean-style diet are less likely to suffer strokes or other brain damage linked to cognitive problems in older people. Compared with people who did not adhere to the diet, those who followed it moderately were 21% less likely to have brain damage, while those who followed the diet most closely saw a 36% risk drop. The study will be presented at the American Academy of Neurology annual meeting.HealthDay News (2/8)

http://healthday.com/Article.asp?AID=635737

Fibrates vs. statins vs. pravastatin: Where's the bleeding risk?
These authors found that initiation of a fibrate or statin that inhibits CYP3A4 enzymes, including atorvastatin, was associated with an increased risk of hospitalization for gastrointestinal bleeding in patients taking warfarin. Initiation of pravastatin, which is mainly excreted unchanged, was not associated with an increased risk. The American Journal of Medicine

Conclusions

Initiation of a fibrate or statin that inhibits CYP3A4 enzymes, including atorvastatin, was associated with an increased risk of hospitalization for gastrointestinal bleeding. Initiation of pravastatin, which is mainly excreted unchanged, was not associated with an increased risk.

http://www.amjmed.com/article/S0002-9343(09)00862-6/fulltext

Optimizing Statin Use at the Population Level: What Is the Best Approach?

In a simulation study, improving patient adherence produced better outcomes than lowering the treatment threshold.

The benefits of statin therapy in patients at risk for coronary disease is unquestioned. However, many patients who would benefit from statin use are not taking them. Expanding statin use could be achieved in two ways: (1) lowering the treatment threshold, or (2) improving adherence. To compare how implementing these strategies would alter the population-level benefit of statin therapy, Shroufi and Powles used data from the prospective Melbourne Collaborative Cohort Study, involving 41,141 participants, to conduct a simulation study.

In the U.K., the National Institute for Health and Clinical Excellence (NICE) recommends that adults with a 20% or greater 10-year risk for heart disease should receive statin therapy. For the model based on a lower treatment threshold, the investigators assumed that adults with a 15.5% or greater 10-year risk would be eligible for statin therapy. For the improved-adherence model, the authors assumed an increase in adherence (defined as taking 80% of the prescribed monthly dose) from 50% to 75%.

The improved-adherence strategy resulted in about twice as large a reduction in cardiovascular deaths as did the lower treatment-threshold strategy. The improved-adherence strategy also showed a modest improvement in averting the onset ofcardiovascular disease, compared with the lower treatment-threshold strategy.

Published in Journal Watch Cardiology February 17, 2010

http://www.ncbi.nlm.nih.gov/pubmed/20056964?dopt=Abstract

How low is too low in glucose control?
This study found that low and high mean HbA1c values were associated with increased all-cause mortality and cardiac events. If confirmed, diabetes guidelines might need revision to include a minimum HbA1c value.

Background

Results of intervention studies in patients with type 2 diabetes have led to concerns about the safety of aiming for normal blood glucose concentrations. We assessed survival as a function of HbA1c in people with type 2 diabetes.

Methods

Two cohorts of patients aged 50 years and older with type 2 diabetes were generated from the UK General Practice Research Database from November 1986 to November 2008. We identified 27 965 patients whose treatment had been intensified from oral monotherapy to combination therapy with oral blood-glucose lowering agents, and 20 005 who had changed to regimens that included insulin. Those with diabetes secondary to other causes were excluded. All-cause mortality was the primary outcome. Age, sex, smoking status, cholesterol, cardiovascular risk, and general morbidity were identified as important confounding factors, and Cox survival models were adjusted for these factors accordingly.

Findings

For combined cohorts, compared with the glycated haemoglobin (HbA1c) decile with the lowest hazard (median HbA1c 7·5%, IQR 7·5—7·6%), the adjusted hazard ratio (HR) of all-cause mortality in the lowest HbA1c decile (6·4%, 6·1—6·6) was 1·52 (95% CI 1·32—1·76), and in the highest HbA1c decile (median 10·5%, IQR 10·1—11·2%) was 1·79 (95% CI 1·56—2·06). Results showed a general U-shaped association, with the lowest HR at an HbA1c of about 7·5%. HR for all-cause mortality in people given insulin-based regimens (2834 deaths) versus those given combination oral agents (2035) was 1·49 (95% CI 1·39—1·59).

Interpretation

Low and high mean HbA1c values were associated with increased all-cause mortality and cardiac events. If confirmed, diabetes guidelines might need revision to include a minimum HbA1c value.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61969-3/abstract

Breast arterial calcium detected on mammography: Not much of a predictor
Breast arterial calcium was not positively associated with cardiovascular risk factors, documented coronary artery disease or acute cardiovascular events, suggesting that the presence of breast arterial calcium as determined by mammography is not a useful predictor of coronary artery disease in intermediate- to high-risk patients. The American Journal of Cardiology

http://www.ajconline.org/article/S0002-9149(09)02410-2/fulltext

Heart Groups Issue Advisory on Cardiovascular Risks with Thiazolidinediones

The American Heart Association and the American College of Cardiology have issued a science advisory summarizing the data on cardiovascular risks associated with the use of thiazolidinedione drugs in type 2 diabetes.

The advisory, published in Circulation, says that there are insufficient data to support the choice of pioglitazone over rosiglitazone. Further, it says the drugs increase the risk for heart failure and "should not be initiated" in patients with class III/IV heart failure.

Citing the "limited and inconclusive" evidence at hand, the advisory concludes that until better data become available, "patients and clinicians will need to weigh the accepted benefits of improved glycemic control on risk for microvascular disease from glucose-lowering agents against the worrisome, i
completely absent information about the effects of these agents on macrovascular

Rosiglitazone Should Be Removed from the Market, Some FDA Staff Advise

Patients may be asking about a New York Times report that some FDA staff are recommending that rosiglitazone, sold in the U.S. as Avandia to treat type 2 diabetes, "be removed from the market."

The story, based on "internal FDA reports" and a Senate Committee on Finance staff report, says that "hundreds of people taking Avandia ... needlessly suffer heart attacks and heart failure each month." The committee report concludes: "The totality of evidence suggests that [GlaxoSmithKline] was aware of the possible cardiac risks associated with Avandia years before such evidence became public."

In separate press releases, GlaxoSmithKline disputes the conclusions, both of the Times article and the Senate report, saying that "the scientific evidence simply does not establish that Avandia increases ischemic cardiovascular risk or causes myocardial ischemic events."

New York Times story (Free)

Senate Committee on Finance report on Avandia (Free PDF)

AAN Releases Guidelines on Treating Muscle Cramps

Although quinine derivatives are "likely effective" for treating muscle cramps, they should not be used routinely because of the potential for adverse events, according to new guidelines from the American Academy of Neurology (AAN).

The guidelines, published in Neurology, specify that quinines should be considered only when cramps are very severe, when other agents haven't helped, and when there can be ongoing monitoring for adverse effects (e.g., hematologic abnormalities, headache).

Among the AAN's other conclusions:

· Vitamin B complex and the calcium channel blocker diltiazem are "possibly effective" and may be considered as treatment.

· Studies of gabapentin (1 trial) and magnesium (2 trials) found no treatment benefit.

· There are no clinical trials evaluating baclofen, carbamazepine, or oxcarbazepine for managing muscle cramps, despite their frequent use for this indication.

· Data are insufficient to recommend for or against calf stretching.

Neurology article (Free)

http://www.neurology.org/cgi/content/full/74/8/691

Aspirin Use Associated with Reduced Risk for Breast Cancer Mortality

Women who use aspirin regularly after breast cancer diagnosis might be less likely to die from the illness, according to an observational study in the Journal of Clinical Oncology.

The analysis included nearly 4200 Nurses' Health Study participants who were diagnosed with stage I, II, or III breast cancer from 1976 to 2002. Aspirin use was assessed via questionnaire beginning one year after diagnosis and until death or June 2006.

Roughly 8% of participants died from breast cancer. After adjustment for cancer stage, treatment, and other confounders, breast cancer mortality was about 70% less likely among women who used aspirin regularly (2–5 days/week or 6–7 days/week), compared with never-users. Distant recurrence was also reduced with regular aspirin use.

The authors suggest several possible mechanisms underlying the observed association, including the potential for aspirin to lower serum estradiol.

http://jco.ascopubs.org/cgi/reprint/JCO.2009.22.7918v1

Muscle Relaxant Adds No Benefit to Ibuprofen for Cervical Strain

Pain relief did not differ among patients who received ibuprofen, cyclobenzaprine, or both drugs.

http://emergency-medicine.jwatch.org/cgi/content/full/2010/205/1?q=etoc_jwgenmed

http://www.ncbi.nlm.nih.gov/pubmed/20078917?dopt=Abstract

Childhood Obesity, Glucose Intolerance, and Hypertension Increase Risk for Premature Adult Mortality Childhood Obesity, but Not Cholesterol, Linked to Death Before 55

High body-mass index, increased levels of glucose intolerance, and hypertension in childhood are all linked to premature death, according to a study of American Indians published in the New England Journal of Medicine.

Researchers assessed the BMI, glucose tolerance, cholesterol, and blood pressure of nearly 5000 nondiabetic children aged 5 to 19 and then followed them for a median of almost 25 years. Rates of death before age 55 among those in the highest quartile of BMI were more than double those with BMIs in the lowest quartile. Similarly, those with the highest levels of glucose intolerance at baseline showed significantly higher premature mortality, as did those with childhood hypertension.

Childhood cholesterol levels showed no association with early death.

The authors conclude that this evidence "underscores the importance of preventing obesity starting in the early years of life."

A possible association between childhood obesity and premature death might be partially mediated by childhood glucose intolerance and hypertension.

Conclusions Obesity, glucose intolerance, and hypertension inchildhood were strongly associated with increased rates of prematuredeath from endogenous causes in this population. In contrast,childhood hypercholesterolemia was not a major predictor ofpremature death from endogenous causes.

Franks PW et al. N Engl J Med 2010 Feb 11; 362:485

http://content.nejm.org/cgi/content/full/362/6/485?linkType=FULL&journalCode=nejm&resid=362/6/485

Population-Based Benefits of Salt Reduction

Daily intake of 3 g less per person could lower annual U.S. cardiac-related deaths by as many as 92,000.

Excessive salt intake is associated with a higher population-based risk for hypertension and coronary heart disease. Current daily mean salt intakes in the U.S. — three quarters of which come from processed foods — are 10.4 g for men and 7.3 g for women (roughly twice the recommended levels). Researchers used validated models for predicting CHD and stroke to estimate benefits that would accrue from lowering salt intake in adults. The investigators assumed that a linear benefit would accrue from lowering daily salt intake by as much as 3 g and that benefits would be accentuated for blacks, people with hypertension, and elders (age, 65).

Lowering daily salt intake by 3 g was estimated to attenuate the annual incidence of CHD by 60,000 to 120,000 cases, of strokes by 32,000 to 66,000, of myocardial infarctions by 54,000 to 99,000, and of cardiac-related deaths by 44,000 to 92,000. Lowering daily salt intake by even 1 g would prevent 15,000 to 32,000 deaths annually. Lowering population-wide daily salt intake by 3 g would have about the same benefit as cutting tobacco use by 50%, lowering body-mass index in obese adults by 5%, giving statins to all adults at low or intermediate risk for CHD, or controlling hypertension in all adults.

Bibbins-Domingo K et al. N Engl J Med 2010 Jan 20;

http://content.nejm.org/cgi/content/abstract/362/7/590

Does Screening Colonoscopy Prevent Right-Sided Cancer?

Findings raise more questions about screening colonoscopy.

In a published case-control study from Canada, screening colonoscopy was associated with lower mortality from left-sided, but not right-sided, colorectal cancer (JW Gastroenterol Feb 20 2009). Now, in another study, investigators have reexamined the issue.

German researchers performed screening colonoscopy in 3287 people (age, 55); 586 had undergone screening colonoscopy within the previous 10 years (average, 5 years previously), and 2701 had never undergone screening colonoscopy. The prevalence of advanced left-sided neoplasia (cancer or advanced adenoma) — from splenic flexure to rectum — was significantly higher in the previously unscreened group than in the previously screened group (9% vs. 3%). However, the prevalence of advanced right-sided neoplasia — from cecum to transverse colon — was similar in the two groups (3%). Adjustment for age, sex, and family history did not change these associations.

Comment: Several studies suggest that screening colonoscopy affords less protection against proximal cancer than against distal cancer. Possible reasons include biological differences between proximal and distal neoplasias, and poorer visualization of the proximal colon due to operator factors or bowel preparation. Randomized trials of screening colonoscopy have not been performed; thus, we must resort to observational studies like this one — despite their limitations — to evaluate the procedure. As noted by editorialists, the findings raise provocative questions about whether the incremental effectiveness of colonoscopy — compared with flexible sigmoidoscopy — is sufficient to justify its greater risk and cost.

CONCLUSION: Prevalence of left-sided advanced colorectal neoplasms, but not right-sided advanced neoplasms, was strongly reduced within a 10-year period after colonoscopy, even in the community setting

http://www.ncbi.nlm.nih.gov/pubmed/20042716?dopt=Abstract

C-Reactive Protein and Cardiovascular Disease: Cause, Mediator, or Marker?

Much of the association between CRP levels and ischemic vascular disease depends on other risk factors.

The Emerging Risk Factors Collaboration. Lancet 2010 Jan 9; 375:132

Lipid Levels and Stroke

In a large meta-analysis, non-HDL cholesterol was associated with risk for ischemic but nothemorrhagic stroke; triglycerides, HDL, and apolipoproteins were not associated with stroke risk. The Emerging Risk Factors Collaboration. JAMA 2009 Nov 11; 302:1993

Smoking Cessation and Risk for Type 2 Diabetes

Excess diabetes risk in quitters is mediated partially by weight gain.

Yeh H-C et al. Ann Intern Med 2010 Jan 5; 152:10

Proteinuria Associated with Adverse Outcomes, Regardless of GFR

Proteinuria independently predicts mortality and other adverse outcomes, regardless of estimated glomerular filtration rate (eGFR), JAMA reports.

Researchers in Canada studied more than 900,000 adults without end-stage kidney disease who had both serum creatinine and proteinuria measured as part of routine care. During a median follow-up of roughly 3 years, 3% of patients died and less than 1% experienced an MI, began renal-replacement therapy, or had a doubling of serum creatinine.

Risks for these adverse outcomes were higher among patients with lower eGFRs and heavier proteinuria. However, at all levels of eGFR — even those not "overtly abnormal" — heavier proteinuria remained an independent predictor of risk.

The authors note that current guidelines for classifying chronic kidney disease are based on eGFR "without explicit consideration of the severity of concomitant proteinuria." They conclude that revisions of such guidelines should take proteinuria into account.

JAMA article (Free)

Androgen Deprivation May Increase CVD Risk, Circulation Statement Warns

It's "reasonable" to conclude that a link may exist between androgen-deprivation therapy (ADT) for prostate cancer and heightened cardiovascular risk, according to a group comprising members of major heart, cancer, and urological societies.

The group's statement, issued online in Circulation, points to published evidence that ADT increases body weight, reduces insulin sensitivity, and adversely affects lipid profiles.

The group makes the following recommendations:

Patients starting ADT should have periodic follow-up with their primary-care physician beginning within 3 to 6 months.

Such evaluations should include assessment of blood pressure, lipid profile, and glucose level.

Glucose and lipids should be checked at least yearly.

Circulation statement (Free PDF)

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192695v1

Do Marine-3 Fatty Acids Slow Cellular Aging?

Telomere length might tie together benefits of fatty acids and exercise.

Farzaneh-Far R et al. JAMA 2010 Jan 20; 303:250